Healthcare Provider Details

I. General information

NPI: 1376139824
Provider Name (Legal Business Name): COLTEN REDDER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 44TH ST SE STE A1106
GRAND RAPIDS MI
49512-4052
US

IV. Provider business mailing address

5730 WILSON AVE SW
WYOMING MI
49418-9354
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-9700
  • Fax: 855-872-6489
Mailing address:
  • Phone: 616-402-3465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302040002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: